Child With Failure To Thrive Health And Social Care Essay

Child With Failure To Thrive Health And Social Care Essay In this review article, the definition, aetiology, evaluation, differential diagnoses, management, prevention and prognosis of failure to thrive are discussed. Failure to thrive (FTT) is a common problem in paediatric practice, affecting 5-10% of under-fives in developed countries with a higher incidence in developing countries. Majority of cases of FTT are due to a combination of nutritional and environmental deprivation secondary to parental poverty and/or ignorance. Many infants with FTT are not identified. The key to diagnosing FTT is finding the time in busy clinical practice to accurately measure and plot a childs weight, height and head circumference, and then assess the trend. In the evaluation of the child who has failed to thrive, three initial steps required to develop an economical treatment-centred approach are: (i) A thorough history including itemized psychosocial review, (ii) Careful physical examination and (iii) Direct observation of the childs behaviour and of parent-child interaction. Laboratory evaluation should be guided by history and physical examination findings only. Once FTT is identified in a particular child, th e management should begin with a careful search for its aetiology. Two principles that hold true irrespective of aetiology are that all children with FTT need a high-calorie diet for catch-up growth (typically 150 percent of their caloric requirement for their expected, not actual weight) and all children with FTT need a careful follow up. Social issues of the family must also be addressed. A multidisplinary approach is recommended when FTT persists despite intervention or when it is severe. Overall, only a third of children with FTT are ultimately judged to be normal. Keywords: Failure to thrive, growth deficiency, undernutrition. INTRODUCTION Although the term failure to thrive (FTT) has been in use in the medical parlance for quite some time now, its precise definition has remained debatable1. consequently, other terms such as undernutrition1 and growth deficiency2 have been proposed as preferable. FTT is a descriptive term applied to young children physical growth is less than that of his or her peers.3 The growth failure may begin either in the neonatal period or after a period of normal physical development.4 The term FTT is not, in itself, a disease but a symptom or sign common to a wide variety of disorders which may have little in common except for their negative effect on growth.5 In this regard, a cause must always be sought. Often, the evaluation of children who fail to thrive pose a difficult diagnostic problem. Some of the difficulties result from the numerous differential diagnoses, the definition used or misdirected tendency to search aggressively for underlying organic diseases while neglecting aetiologies based on environmental deprivation.6 In addition, early accusations and alienation of the childs parents by the health-care provider will make the evaluation and management of the child who has failed to thrive more difficult.7 In general, factors that influence a childs growth include: (i) A childs nutritional status; (ii) A childs health; (iii) Family issues; and (iv) The parent-child interactions.3,8,9 All these factors must be considered in evaluation and management of child who has failed to thrive. This paper presents a simplified but detailed approach to the evaluation and management of the child with FTT. DEFINITION The best definition for FTT is the one that refers to it as inadequate physical growth diagnosed by observation of growth over time using a standard growth chart, such as the National Center for Health Statistics (NCHS) growth chart.10 All authorities agree that only by comparing height and weight on a growth chart over time can FTT be assessed accurately.11 So far, no consensus has been reached concerning the specific anthropometric criteria to define FTT.11 Consequently, where serial anthropometric records is not available, FTT has been variously defined statistically. For instance, some authors defined FTT as weight below the third percentile for age on the growth chart or more than two standard deviations below the mean for children of the same age and sex1-3 or a weight-for-age (weight-for-hieght) Z-score less than minus two.1 Others cite a downward change in growth that has crossed two major growth percentiles in a short time.3 Still others, for diagnostic purposes, defined FTT as a disproportionate failure to gain weight in comparison to height without an apparent aetiology.6 Brayden et al.,2 suggested that FTT should be considered if a child less than 6 months old has not grown for two consecutive months or a child older than 6 months has not grown for three consecutive months. Recent research has validated that the weight-for-age approach is the simplest and most reasonable marker of FTT.12 Pitfalls of these definitions: One limitation of using the third percentile for defining FTT is that some children whose weight fall below this arbitrary statistical standard of normal are not failing to thrive but represent the three percent of normal population whose weight is less than the third percentile.5,6 In the first 2 years of life, the childs weight changes to follow the genetic predisposition of the parents height and weight.13,14 During this time of transition, children with familial short stature may cross percentiles downward and still be considered normal.14 Most children in this category find their true curve by the age of 3 years.6,14 When the percentile drop is great, it is helpful to compare the childs weight percentile to height and head circumference percentiles. These should be consistent with the position of height and head circumference percentiles of the patient.5 Another limitation of the third percentile as a criterion to define FTT is that infants can be failing to thrive with marked d eceleration of weight gain, but they remain undiagnosed and therefore, untreated until they have fallen below the arbitrary third percentile.6 These normal small children do not demonstrate the disproportionate failure to gain weight that children with FTT do.6 This approach attempts not only to prevent normal small children from being incorrectly labeled as failing to thrive, but also excludes children with pathologic proportionate short stature.14 Having excluded these easily distinguishable disorders from the differential diagnosis of FTT, simplifies the approach to evaluation of the child who has failed to thrive.6 A more encompassing definition of FTT includes any child whose weight has fallen more than two standard deviations from a previous growth curve.3,15,16 Normal shifts in growth curves in the first 2 years of life will result in less severe decline (i.e, less than 2 SD).13 Some authors have even limited the definition of FTT to only children less than 3 years old17,18 A precise age limitation is arbitrary. However, most children with FTT are under 3 years of age.6,8 EPIDEMIOLOGY In young children, FTT which does not reach the severe classical syndrome of marasmus is common in all societies.19 However, the true incidence of FTT is not known as many infants with FTT are not identified, even in developed countries.20-22 It is estimated to affect 5 10% of young children and approximately 3 5% of children admitted into teaching hospitals.3,5,23 Mitchell et al,24 using multiple criteria found that nearly 10% of under-fives attending primary health care centre in the United States showed FTT. About 5% of paediatric admissions in United Kingdom are for FTT.4 The prevalence is even higher in developing countries with wide-spread poverty and high rates of malnutrition and/or HIV infections.3,19 Children born to single teenage mothers and working mothers who work for long hours are at increased risk.22 The same is true of children in institutions such as orphanage homes and homes for the mentally retarded5,22 with an estimated incidence of 15% as a group.5 Under-feed ing is the single commonest cause of FTT and results from parental poverty and/or ignorance.19,22,24 Ninety five percent of cases of FTT are due to not enough food being offered or taken.25 The peak incidence of FTT occurs in children between the age of 9 24 months with no significant sex difference.22 Majority of children who fail to thrive are less than 18 months old.3 The syndrome of FTT is uncommon after the age of 5 years.3,22 AETIOLOGY Traditionally, causes of FTT have been classified as non-organic and organic. However, some authors have stated that this terminology is misleading.27 They based their opinion on the fact that all cases of FTT are produced by inadequate food or undernutrition and in that context, is organically determined. In addition, the distinction based on organic and non-organic causes is no longer favoured because many cases of FTT are of mixed aetiologies.3 Based on pathophysiology (the preferred classification), FTT may be classified into those due to: (i) Inadequate caloric intake; (ii) Inadequate absorption; (iii) Increased caloric requirement; and (iv) Defective utilization of calories. This classification leads to a logical organization of the many conditions that cause or contribute to FTT.10 Non organic (psychosocial) failure to thrive In non-organic failure to thrive (NFTT), there is no known medical condition causing the poor growth. It is due to poverty, psychosocial problems in the family, maternal deprivation, lack of knowledge and skill in infant nutrition among the care-givers5,11. Other risk factors include substance abuse by parents, single parenthood, general immaturity of one or both parents, economic stress and strain, temporary stresses such as family tragedies (accidents, illnesses, deaths) and marital disharmony.6,8,22 Weston et al,28 reported that 66% of mothers whose infants failed to thrive has a positive history of having been abused as children themselves, compared to 26% of controls from similar socioeconomic background. NFTT accounts for over 70% of cases of FTT.6 Of this number, approximately one-third is due to care-givers ignorance such as incorrect feeding technique, improper preparation of formula or misconception of the infants nutritional needs,29 all of which are easily corrected. A cl ose look at these risk factors for NFTT suggest that infants with growth failure may represent a flag for serious social and psychological problems in the family. For example, a depressed mother may not feed her infant adequately. The infant may, in turn, become withdrawn in response to mothers depression and feed less well.10 Extreme parental attention, either neglect or hypervigilance, can lead to FTT.10 Organic failure to thrive It occurs when there is a known underlying medical cause. Organic disorders causing FTT are most commonly infections (e.g HIV infection, tuberculosis, intestinal parasitosis), gastrointestinal (e.g., chronic diarrhoea, gastroesophageal reflux, pyloric stenosis) or neurologic (e.g., cerebral palsy, mental retardation) disorders.6,19,22 Others include genitourinary disorders (e.g., posterior urethral valve, renal tubular acidosis, chronic renal failure, UTI), congenital heart disease, and chromosomal anomalies.6,7 Together neurologic and gastrointestinal disorders account for 60 80% of all organic causes of under nutrition in developed countries.30 An important medical risk factor for under nutrition in childhood is premature birth.1 Among preterm infants, those who are small for gestational age are particularly vulnerable since prenatal factors have already exerted deleterious effect on somatic growth.1 In societies where lead poisoning is common, it is a recognized risk factor for p oor growth.5,31 Organic FTT virtually never presents with isolated growth failure, other signs and symptoms are generally evident with a detailed history and physical examination.32 Organic disorders accounts for less than 20% of cases of FTT.6 Mixed failure to thrive In mixed FTT, organic and non organic causes coexist. Those with organic disorders may also suffer from environmental deprivation. Likewise, those with severe undernutrition from non-organic FTT can develop organic medical problems. FTT with no specific aetiology Review of the literature on FTT indicate that in 12 32% of cases of children who have failed to thrive, no specific aetiology could be established.23,33-34 Causes of failure to thrive A. Prenatal cases: (i) Prematurity with its complication (ii) Toxic exposure in utero such as alcohol, smoking, medications, infections (eg rubella, CMV) (iii) Intrauterine growth restriction from any cause (iv) Chromosomal abnormalities (eg Down syndrome, Turner syndrome) (v) Dysmorphogenic syndromes. B. Postnatal causes based on pathophysiology: A. Inadequate caloric intake which may result from: i. Under feeding Incorrect preparation of formula (e.g. too dilute, too concentrated). Behaviour problems affecting eating (e.g., childs temperament). Unsuitable feeding habits (e.g., uncooperative child) Poverty leading to food shortages. Child abuse and neglect. Mechanical feeding difficulties e.g., congenital anomalies (cleft lip/palate), oromotor dysfunction. Prolonged dyspnoea of any cause B. Inadequate absorption which may be associated with: Malabsorption syndromes e.g. Celiac disease, cystic fibrosis, cows milk protein allergy, giardiasis, food sensitivity/intolerance Vitamins and mineral deficiencies e.g., zinc, vitamins A and C deficiencies. Hepatobiliary diseases e.g., biliary atresia. Necrotizing enterocolitis Short gut syndrome. C. Increased Caloric requirement due to Hyperthyroidism Chronic/recurrent infections e.g., UTI, respiratory tract infection, tuberculosis, HIV infection Chronic anaemias D. Defective Utilization of Calories Inborn errors of metabolism e.g., galactosaemia, aminoacidopathies, organic acidurias and storage diseases. Diabetes inspidus/mellitus Renal tubular acidosis Chronic hypoxaemia Clinical manifestations of FTT3,22 Commonly the parents/care-givers may complain that the child is not growing well or losing weight or not feeding well or not doing well or not like his other siblings/age mates. Usually FTT is discovered and diagnosed by the infants physician using the birthweight and health clinic anthropometric records of the child. The infant looks small for age. The child may exhibit loss of subcutaneous fat, reduced muscle mass, thin extremities, a narrow face, prominent ribs, and wasted buttocks, Evidence of neglected hygiene such as diaper rash, unwashed skin, overgrown and dirty fingernails or unwashed clothing. Other findings may include avoidance of eye contact, lack of facial expression, absence of cuddling response, hypotonia and assumption of infantile posture with clenched fists. There may be marked preoccupation with thumb sucking. EVALUATION A. Initial evaluation It has been proposed that only three initial investigations are required to develop an economical, treatment-centred approach to the child who presents with FTT and this include:35 (i) A thorough history including an itemized psychosocial review; (ii) Careful physical examination including determination of the auxological parameters; and (iii) Direct observation of the childs behaviour and of parent-child interactions. The Psychosocial Review: The psychosocial history should be as thorough and systematic as a classic physical examination Goldbloom35 suggested that the interviewers should ask themselves three questions about every family: (i) How do they look; (ii) What do they say; and (iii) What do they do? a. HISTORY (1) Nutritional history Nutritional history should include: Details of breast feeding to get an idea of number of feeds, time for each feeding, whether both breasts are given or one breast, whether the feeding is continued at night or not and how is the childs behaviour before, after and in between the feeds. It would give an idea of the adequacy or inadequacy of mothers milk. If the infant is on formula feeding: Is the formula prepared correctly? Dilute milk feed will be poor in calorie with excess water. Too concentrated milk feed may be unpalatable leading to refusal to drink. It is also essential to know the total quantity of the formula consumed. Is it given by bottle or cup and spoon? Also assess the feeling of the mother e.g., ask how do you feel when the baby does not feed well? Time of introduction of complementary feeds and any difficulty should be noted. Vitamin and mineral supplement; when started, type, amount, duration. Solid food; when started, types, how taken. Appetite; whether the appetite is temporarily or persistently impaired (if necessary calculate the caloric intake). For older children enquire about food likes and dislikes, allergies or idiosyncracies. Is the child fed forcibly? It is desirable to know the feeding routine from the time the child wakes up in the morning till he sleeps at night, so that one can get an idea of the total caloric intake and the calories supplied from protein, fat and carbohydrate as well as adequacy of vitamins and minerals intake. (2) Past and current medical history The history of prenatal care, maternal illness during pregnancy, identified fetal growth problems, prematurity and birth weight. Indicators of medical diseases such as vomiting, diarrhoea, fever, respiratory symptoms and fatigue should be noted. Past hospitalization, injuries, accidents to evaluate for child abuse and neglect. Stool pattern, frequency, consistency, presence of blood or mucus to exclude malabsorption syndromes, infection and allergy. (3) Family and social history Family and social history should include the number, ages and sex of siblings. Ascertain age of parents (Down syndrome and Klinerfelter syndrome in children of elderly mothers) and the childs place in the family (pyloric stenosis). Family history should include growth parameters of siblings. Are there other siblings with FTT (e.g., genetic causes of FTT), family members with short stature (e.g. familial short stature). Social history should determine occupation of parents, income of the family, identify those caring for the child. Child factors (e.g., temperament, development), parental factors (e.g., depression, domestic violence, social isolation, mental retardation, substance abuse) and environmental and societal factors (e.g., poverty, unemployment, illiteracy) all may contribute to growth failure.5 Historical evaluation of the child with FTT is summarized in Table 1. (b) PHYSICAL EXAMINATION The four main goals of physical examination include (i) identification of dysmorphic features suggestive of a genetic disorder impeding growth; (ii) detection of under lying disease that may impair growth; (iii) assessment for signs of possible child abuse; and (iv) assessment of the severity and possible effects of malnutrition.36,37 The basic growth parameters such as weight, height / length, head circumference and mid-upper-arm circumference must be measured carefully. Recumbent length is measured in children below 2 years of age because standing measurements can be as much as 2cm shorter.36,37 Other anthropometric data such as upper-segment-to-lower-segment ratio, sitting height and arm span should also be noted. The anthropometric index used for FTT should be weight-for-length or height. Mid-parental height (MPH) should be determined using the formula.40 For boys, the formula is: MPH = [FH + (MH 13)] 2 For girls, the formula is: MPH = [(FH 13) + MH] 2 In both equations, FH is fathers height in centimetres and MH is mothers height in centimetres. The target range is calculated as the MPH Â ± 8.5cm, representing the two standard deviation (2SD) confidence limits.14 Assessment of degree FTT The degree of FTT is usually measured by calculating each growth parameter (weight, height and weight/height ratio) as a percentage of the median value for age based on appropriate growth charts3 (See Table 3) Table 3: Assessment of degree of failure to thrive (FTT) Growth parameter Degree of Failure to Thrive Mild Moderate Severe Weight 75-90% 60 -74% Height 90 -95% 85 89% Weight/height ratio 81-90% 70 -80% Adapted from Baucher H.3 It should be noted that appropriate growth charts are often not available for children with specific medical problems, therefore serial measurements are especially important for these children.3 For premature infants, correction must be made for the extent of prematurity. Corrected age, rather than chronologic age, should be used in calculations of their growth percentiles until 1-2 years of corrected age.3 Table 2: Physical examination of infants and children with growth failure. Abnormality Diagnostic Consideration Vital signs Hypotension Hypertension Tachypnoea/Tachycardia Adrenal or thyroid insufficiency Renal diseases Increased metabolic demand Skin Pallor Poor hygiene Ecchymoses Candidiasis Eczema Erythema nodosum Anaema Neglect Abuse Immunodeficiency, HIV infection Allergic disease Ulcerative colitis, vasculitis HEENT Hair loss Chronic otitis media Cataracts Aphthous stomatitis Thyroid enlargement Stress Immunodeficiency, structural oro- facial defect Congenital rubella syndrome, galactosaemia Crohns disease Hypothyroidism Chest Wheezes Cystic fibrosis, asthma Cardiovascular Murmur Congenital heart disease(CHD) Abdomen Distension hyperactive Bowel sound Hepatosplenomegaly Malabsorption Liver disease, glycogen storage disease Genitourinary Diaper rashes Diarrhoea, neglect Rectum Empty ampulla Hirschsprungs disease Extremities Oedema Loss of muscle mass Clubbing Hypoalbuminaemia Chronic malnutrition Chronic lung disease, Cyanotic CHD Nervous system Abnormal deep tendon Reflexes Developmental delay Cranial nerve palsy Cerebral palsy Altered caloric intake or requirements Dysphagia Behaviour and temperament Uncooperative Difficult to feed. Adapted from Collins et al 41 Growth charts should be evaluated for pattern of FTT. If weight, height and head circumference are all less than what is expected for age, this may suggest an insult during intrauterine life or genetic/chromosomal factors.2 If weight and height are delayed with a normal head circumference, endocrinopathies or constitutional growth should be suspected.2 When only weight gain is delayed, this usually reflects recent energy (caloric) deprivation.2 Physical examination in infants and children with FTT is summarized in Table 2. Failure to thrive due to environmental deprivation Children with environmental deprivation primarily demonstrate signs of failure to gain weight: loss of fat, prominence of ribs and muscles wasting, especially in large muscle groups such as the gluteals.6 Developmental assessment It is important to determine the childs developmental status at the time of diagnosis because children with FTT have a higher incidence of developmental delays than the general population.36 With environmental deprivation, all milestones are usually delayed once the infant reaches 4 months of age.42 Areas dependent on environmental interactions such as language development and social adaptation are often disproportionately delayed. Specific behavioural evaluations (e.g., recording responses to approach and withdrawal), have been developed to help differentiate underlying environmental deprivation from organic disease.43 Assess the infants developmental status with a full Denver Developmental Standardized test.44 Parent-child interaction: Evaluate interaction of the parents and the child during the examination. In environmental deprivation, the parent often readily walks away from the examination table, appearing to easily abandon the child to the nurse or physician.6 There is little eye contact between child and parent and the infant is held distantly with little moulding to the parents body.6 Often the infant will not reach out for the parent and little affectionate touching is noted.6 There is little parental display of pleasure towards the infant.6 Observation of feeding is an integral part of the examination, but it is ideally done when the parents are least aware that they are being observed. Breast-fed infants should be weighed before and after several feedings over a 24-hour period since volume of milk consumed may vary with each meal. In environmental deprivation, the parents often miss the infants cues and may distract him during feeding; the infant may also turn away from food and appear distressed.6 Unnecessary force may be used during feeding. Developing a portrait of the child-parent relationship is a key to guiding intervention.11 LABORATORY EVALUATION The role of laboratory studies in the evaluation of FTT is to investigate for possible organic diagnoses suggested by the history and physical examination.33,34 If an organic aetiology is suggested, appropriate studies should be undertaken. If history and physical examination do not suggest an organic aetiology, extensive laboratory test is not indicated.6 However, on admission full blood count, ESR, urinalysis, urine culture, urea and electrolyte (including calcium and phosphorus) levels should be carried out. Screen for infections such as HIV infection, tuberculosis and intestinal parasitosis. Skeletal survey is indicated if physical abuse is strongly suspected. In addition to being unproductive, blind laboratory fishing expeditions should be avoided for the following reason:5,6 (i) they are expensive; (ii) they impair the childs ability to gain weight in a new environment both by frightening him/her with venepuncture, barium studies and other stressful procedures and the no oral f eeds associated with some investigations prevent him/her from getting enough calories; (iii) they can be misleading since a number of laboratory abnormalities are associated with psychosocial deprivation (e.g., increased serum transaminases , transient abnormalities of glucose tolerance, decreased growth hormone and iron deficiency);21 and (iv) they divert attention and resources from the more productive search for evidence of psychosocial deprivation. In one study, a total of 2,607 laboratory studies were performed, with an average of 14 tests per patient. With all tests considered, only 10(0.4%) served to establish a diagnosis and an additional 1% were able to support a diagnosis.34 Further Evaluation (1) Hospitalization: Although some authors state that most children with failure to thrive can be treated as outpatients,4,5,11,45 I think it is best to hospitalize the infant with FTT for 10 14 days. Hospitalization has both diagnostic and therapeutic benefits. Diagnostic benefits of admission may include observation for feeding, parental-child interaction, and consultation of sub-specialists. Therapeutic benefits include administration of intravenous fluids for dehydration, systemic antibiotic for infection, blood transfusion for anaemia and possibly, parenteral nutrition, all of which are often in-hospital procedures. In addition, if an organic aetiology is discovered for the FTT, specific therapy can be initiated during hospitalization. In psychosocial FTT, hospitalization provides opportunity to educate parents about appropriate foods and feeding styles for infants. Hospitalization is necessary when the safety of the child is a concern. In most situations in our set up, there i s no viable alternative to hospitalization. (2) Quantitative assessment of intake: A prospective 3-day diet record should be a standard part of the evaluation. This is useful in assessing under nutrition even when organic disease is present. A 24-hour food recall is also desirable. Having parents write down the types of food and amounts a child eats over a three-day is one way of quantifying caloric intake. In some instances, it can make parents aware of how much the child is or is not eating.11 Table 4: Summary of risk factors for the development of failure to thrive Infant characteristics Any chronic medical condition resulting in: Inadequate intake (e.g, swallowing dysfunction, central nervous system depression, or any condition resulting in anorexia) Increased metabolic rate (e.g, bronchopulmonary dysplasia, congenital heart disease, fevers) Maldigestion or malabsorption (e.g, AIDS, cystic fibrosis, short gut, inflammatory bowel disease, celiac disease). Infections (e.g., HIV, TB, Giardiasis) Premature birth (especially with intrauterine growth restriction) Developmental delay Congenital anomalies Intrauterine toxin exposure (e.g. alcohol) Plumbism and/or anaemia Family characteristics Poverty Unusual health and nutrition beliefs Social isolation Disordered feeding techniques Substance abuse or other psychopathology (include Muschausen syndrome by proxy) Violence or abuse Adapted from Kleinman RE.1 Table 1: Summary of historical evaluation of infants and children with growth failure Prenatal General obstetrical history Recurrent miscarriages Was the pregnancy planned? Use of medications, drugs, or cigarettes Labour, delivery, and neonatal events Neonatal asphyxia or Apgar scores Prematurity Small for gestational age Birth weight and length Congenital malformations or infections Maternal bonding at birth Length of hospitalization Breastfeeding support Feeding difficulties during neonatal period Medical history of child Regular physician Immunizations Development Medical or surgical illnesses Frequent infections Growth history Plot previous points Nutrition history Feeding behavior and environment Perceived sensitivities or allergies to foods Quantitative assessment of intake (3-day diet record, 24-hour food recall) Social history Age and occupation of parents Who feeds the child? Life stresses (loss of job, divorce, death in family) Availability of social and economic support (Special Supplemental Nutrition Program for Women, Infants and Children; Aid for Families with Dependent Chi

How Does Steinbeck Present Disadvantaged Characters

Explore some of the ways in which Steinbeck presents disadvantaged characters in the novel In 1937, the American author John Steinbeck published ‘Of mice and Men'. Set in the Salinas Valley of California, it conveys the story of the struggles of the American people during ‘The Great Depression'. The Great Depression was a massive devastation throughout the whole of America where people suffered and the economy was at a huge crisis. The Unemployment rose from 3% to 26% and many people had died, showing how hard the citizens coped to survive in-between this difficult period.The Americans were in a depriving financial state full of high inflation after an economic fall known as the ‘The Wall Street Crash' The nation only helped themselves by believing in their own dreams, which meant mostly to have their own lands, be rich and live a good-life- â€Å"The American Dream†. This ideology gave the public hopes of life and something to work towards. John Steinbeck do es not only explore how people struggled for their American dream, but also describes how difficult this melancholy period in history was for the â€Å"lesser† group of individuals at the time: the disadvantaged characters.Lennie, a big simple-minded character, is a highly disadvantaged individual due to poor mental health. As Lennie is one of the predominant characters in ‘Of Mice and Men’, he is perhaps the least dynamic. He experiences no change in developing or growing in mental or practical abilities; the plain figure remains as illustrated at the start of the opening pages in the novel. Although his character is displayed in this way, despite being under privileged he is based as a central protagonists in the story. Steinbeck conveys a general initiative to his readers that, Lennie’s actions make great affection.Being basic makes his choices morally incorrect- this shows his difficulties. Steinbeck uses the character of Lennie to symbolise the mental ly underprivileged people of this period. â€Å"Let's have different colour rabbits, George. †Pg 16 â€Å"Just ain’t bright†24 Steinbeck shows his readers the stage of which Lennie's mind is developed; still like a child's, even though he is a fully-grown man. From the start of the novella, the reader must know that Steinbeck creates an illustration of Lennie as sadly being doomed, and must be sympathetic towards him.This is a construction built to present to the reader at the current time of the 1920's a huge disadvantage to the mentally handicapped society. The simple-minded character of Lennie also leads him to lack in responsibility and trust. He is shown to have no knowledge of any financial or general life problems, therefore Steinbeck creates a main part for George to play in, and this is where he has to take the weight on his shoulders for Lennie. †if you jus' happen to get in trouble like you always done before, I want you to come right here an' h ide in the brush†, †Leggo his hand, Lennie†, 64 You tol' me to George,†64 The author is trying to portray an image to his readers that Lennie cannot think for his self and has to be controlled; this is another big under privilege towards the mentally handicapped people. Lennie also speaks without grammatical sense and this shows he is uneducated and not taught to talk proper English, â€Å"they was so little† pg 11 â€Å"Don't tell nobody† PG61 Lastly the biggest let down for the simple minded figure is not being able to adapt a level of understanding to the normal person , Lennie cannot tell the strength he applies or has when used.This makes him very innocent when attacking someone without knowing, He also loves to pet animals and furry material but while this process, as he is a strong figure, he kills the being. †'Don't you go yellin', he said, and shook her; and her body flopped like a fish. And then she was still, for Lennie had brok en her neck. †90 The author uses the word ‘and' repetitively showing how dramatic the moment is. Steinbeck depicts towards his audience that Lennie was only trying to quite Curley’s wife but accidentally fails as he cannot handle his abnormal great strength.This use of dramatics and panic shows where Lennie is innocent. From my view I think Lennie is also based upon the theme of an animal, there are areas where Steinbeck refers to Lennie as animal like â€Å"He’s as strong as a bull† â€Å"the way a bear drags his pours† In addition, Steinbeck uses the comparison of Candy's dog and Lennie to depict the value and status of less mentally capable individuals. Just how candy's dog is eradicated once he becomes ‘useless', the same image is created for Lennie as his fate is controlled and chosen by the ‘normal' ranch hands.Similarly, The death of Lennie, is constructed as an illustration towards the readers that his own friend kills him because it is a ‘necessity'. The author is portraying to his readers that even George, Lennie's tightest companion, shoots him out of sympathy so his friend does not go through the wrath of Curley's torturing death. This conveys to us that the people of the 1930's thought it was right to choose a death of a mentally handicapped because it was ‘obligatory',Of mice and men, shows a greater emphasised picture, where a very close friendship is ended.The dramatics used by Steinbeck when showing us George kills his best colleague Lennie, tells the reader how life was a great hardship for the discrimination against the mentally handicapped, especially when it was very unlikely to see two friends travelling together. The book demonstrates this concept by putting the ‘rights' of a dog identical to the ‘rights' of a mentally incapable person. Today, this sought of situation is taken seriously, where the rights for any being is equally judged. Steinbeck presents another character which I think is one of the most hindered upon-Crooks.Crooks is highly discriminated, especially at this time, because he is black. He is a black man that lives in America at the time of segregation from the colour of his skin. This was tragic and sad for the black community as they were marginal. Living as a black man being employed was one of the most hardest job, this caused a lot of unemployment for the ‘coloured' public . The only upper hand crooks had was a job in the ranch, it still was very risky, the boss beat him for no reason, but this was all he could do for a living. S'pose you didn't have nobody. S'pose you couldn't go to the bunk house and play rummy 'cause you was black. †72. Steinbeck often demonstrates towards his audience that Crooks is a victim of isolation and loneliness, this illustrates the high level of prejudice and separation against the black ethnic minority of the 1930s. Crooks use of the word ‘S'pose' twice in short time to s how the emphasis of his feelings. The appearance and physical disability of Crooks also makes him impoverished, he has a crooked back and thus is called by the name ‘Crooks ‘. Now and then he poured a few drops of the liniment into his pink-palmed hand and reached up under his shirt to rub again.He flexed his muscles against his back and shivered. †67. Steinbeck provides his readers with a description for the appearance of Crooks. This description shows us where ‘Crooks' is named by the ranch hands. When Steinbeck uses this method, he produces nicknames to portray to his readers how the men do not take any interest in knowing a full name; this shows the loneliness. The black community was often assaulted by the white public, this was a great hardship in the 1930's. I could get you strung up on a tree so easy it ain't even funny. †80 â€Å"Crooks had reduced himself to nothing. There was no personality, no ego- nothing to arouse either like or dislike. †80. The black minority was too downgraded and this quote is evident. When any black man spoke for his self, he was threatened and could not fight on. Steinbeck expresses to his readers how life was for the black people when abused. As he is black, Crooks is segregated from the other workers, this causes a great amount of desolation, he is trapped in solitude day and night and resorts to reading books.In the novel, when Lennie enters Crooks room, at first his reaction is to be alone and unwanted but then his lack of unsociability wins over him and allows Lennie to set in. During his conversation, Crooks reveals his sorrow of being alone, segregated and divined from others. â€Å"I seen it over an’ over a guy talkin’ to another guy and it don’t make no difference if he don’t hear or understand. † He is referring to Lennie but actually talking of himself. Steinbeck creates an image to his reader, how the life of someone already disliked, depriv es as he is lonely and separated.In the 1930's, Steinbeck shows his readers where the black people's status stood and where they were disadvantaged. The use of the word ‘n**ger' was normal for people to remark, this just portrays how downgraded the black community were. I think as Crooks was in the bracket of an ethnic minority, he was extremely unlucky and discriminated, the author shows us another disadvantaged character based at the time of the novella. From the perspective of Curley's wife, I think that John Steinbeck uses analogy to represent the place for woman and how they were the underdogs towards the men.Living in the male world, Curleys wife is mostly shown as a bad sign as she is an uncommon person in the ranch. She undergoes a difficult and antagonistic period through her life. â€Å"You wasn't no good. You ain't no good now, you lousy tart†94 â€Å"Well, ain't she a looloo? †51 â€Å"I ain't seen that much of her, PG 51 When whit describes her as t his it shows what they think of her, also the emphasis of George speaking when saying, â€Å"I ain't seen that much of her,† shows the care and intensity that he does not give when he replies. In the beginning of the novel, Steinbeck introduces Curley’s wife through Candy’s description.The critical comments leave the reader to have a negative opinion; as she seems to be a woman in a male world. ‘I’ve seen her give slim the eye†¦ an’ I’ve seen her give Carlson the eye. ’ (pg 29)    By classifying Curley’s wife as a ’flirt’, she is effectively prohibited from the men. There are certain areas where Curleys wife's image is described evil and unhappy, Steinbeck tries to portray towards his readers that when she is there the mood is struck negatively and falls immediately at her presence, â€Å"Both men glanced up, for the rectangle of sunshine in the doorway was cut off. A girl was standing there looking in.She had full, rouged lips and wide-spaced eyes, heavily made up. Her fingernails were red. Her hair hung in little rolled clusters, like sausages. She wore a cotton house dress and red mules, on the insteps of which were little bouquets of red ostrich feathers. â€Å"I'm lookin' for Curley,†she said. Her voice had a nasal, brittle quality. †PG 32 From this extract of the book, there are different ways in which the author describes Curley's wife as a cynical approach at this moment of the story. Steinbeck shows us that as soon as she comes in the sunlight is cut off- blocking the admirable scene.Even with the clothing, Curley's wife wears a lot of the colour red conveying the evil colour and the emphasis of her voice when she speaks,† Her voice had a nasal, brittle quality. † Steinbeck describes the disadvantages women had when she is first illustrated. Throughout the book, Curley's wife's character is fairly mysterious and complicated. She is continuously referred to as her husband's belonging or possession, this shows us where she is unidentified, through this misidentification we can figure out her status as a woman; she did not need to be known.Steinbeck’s use of identification against Curley’s wife is her most disadvantage. When someone has no identification, it describes to the reader where his or her reputation is, the name Curley’s wife portrays an image that her name is a tool, owned by her husband and is not much importance. Through the book she is foreshadowed in many areas, where her sly flirty actions lead to hazardous trouble, despite this matter, when reading between the lines, the reader is made to show some part of sympathy to express towards her.The author also uses other ways to describe the loneliness and emotions in the book, words like ‘solitaire' (meaning ‘ a card game played by one person), shows us how he referred to the people working at the ranch as desolate and unsocial, he also uses nick names, except for George and Lennie, such as â€Å"Slim† or â€Å"Curley†, this is another sign, of the low and sad mood. In the novel, there are a few areas where the writer presents short snappy sentences to show the effects, â€Å"The silence came into the room. And the silence lasted†. 9 Additionally, Steinbeck chooses the use of circulation in situations, just like a life cycle, In each chapter the setting in the beginning is the setting at the end, this conveys a message that the situation always ends at point one, , for example Lennie and George have a dream in the beginning which is just a plain dream that has no hope, it develops as the book stages itself at chapter 3 ,in the middle, there is sudden hope and it looks like an easy grab, but it circulates and drops back down, where Lennie kills Curley's wife, this illustrates the method of death and that there is no hope left.John Steinbeck the author reveals to his audience how, in a gene ral view, people were highly disadvantaged especially at the time of discrimination towards them. He mentions three obvious characters , Lennie, Crooks and Curley's wife. These individuals all have main deficiencies and all have different types of disadvantages. Steinbeck uses a mentally handicapped individual, a black physically disabled man and a women in a male's world, this shows us an occurring pattern from the author, trying to describe the sadness and discrimination to people at the time of ‘The Great Depression'The novel, ‘Of Mice and Men’ depicts to the readers how the daily struggles for the working class were, being greatly underprivileged and the reality of failing plans for a living, resembling ‘The American Dream’. John Steinbeck shows his audience individuals who constantly face one problem after another. Moreover, he describes people of America who struggled a torrid time through â€Å"Survival of the fittest†, especially the di scriminated.

Karl Marx and a Sociology Subfield

Marxist sociology is a way of practicing sociology that draws methodological and analytic insights from the work of Karl Marx. Research conducted and theory produced from the Marxist perspective focuses on the key issues that concerned Marx: the politics of economic class, relations between labor and capital, relations between culture, social life, and economy, economic exploitation, and inequality, the connections between wealth and power, and the connections between critical consciousness and progressive social change. There are significant overlaps between Marxist sociology and conflict theory, critical theory, cultural studies, global studies, the sociology of globalization, and the sociology of consumption. Many consider Marxist sociology a strain of economic sociology. History and Development of Marxist Sociology Though Marx was not a sociologist—he was a political economist—he is considered one of the founding fathers of the academic discipline of sociology, and his contributions remain mainstays in the teaching and practice of the field today. Marxist sociology emerged in the immediate aftermath of Marxs work and life, at the end of the 19th century. Early pioneers of Marxist sociology included the Austrian Carl Grà ¼nberg and the Italian Antonio Labriola.  Grà ¼nberg became the first director of the Institute for Social Research in Germany, later referred to as the Frankfurt School, which would become known as a hub of Marxist social theory  and the birthplace of critical theory. Notable social theorists that embraced and furthered the Marxist perspective at the Frankfurt School include Theodor Adorno, Max Horkheimer, Erich Fromm, and Herbert Marcuse. The work of Labriola, meanwhile, proved fundamental in shaping the intellectual development of the Italian journalist and activist Antonio Gramsci. Gramscis  writings from prison during the Fascist regime of Mussolini laid the groundwork for the development of a cultural strand of Marxism, the legacy of which features prominently within Marxist sociology. On the cultural side in France, Marxist theory was adapted and developed by Jean Baudrillard, who focused on consumption rather than production. Marxist theory also shaped the development of the ideas of Pierre Bourdieu, who focused on relationships between economy, power, culture, and status. Louis Althusser was another French sociologist who made expanded on Marxism in his theory and writing, but he focused on social structural aspects rather than culture. In the U.K., where much of Marxs analytic focus lied while he was alive, British Cultural Studies, also known as the Birmingham School of Cultural Studies was developed by those who focused on the cultural aspects of Marxs theory, like communication, media, and education. Notable figures include Raymond Williams, Paul Willis, and Stuart Hall. Today, Marxist sociology thrives around the world. This vein of the discipline has a dedicated section of research and theory within the American Sociological Association. There are numerous academic journals that feature Marxist sociology. Notable ones include  Capital and Class,  Critical Sociology,  Economy and Society,  Historical Materialism, and  New Left Review. Key Topics Within Marxist Sociology The thing that unifies Marxist sociology is a focus on the relationships between economy, social structure, and social life. The following are key topics that fall within this nexus. The politics of economic class, especially the hierarchies, inequities, and inequalities of a society structured by class: Research in this vein often focuses on class-based oppression and how it is controlled and reproduced through the political system, as well as through education as a social institution.Relations between labor and capital:  Many sociologists focus on how the conditions of work, wages, and rights of workers differ from economy to economy (capitalism versus social, for example), and how these things shift as economic systems shift, and as technologies that influence production evolve.  Relations between culture, social life, and economy:  Marx paid close attention to the relationship between what he called the base and superstructure, or the connections between the economy and relations of production and the cultural realm of ideas, values, beliefs, and worldviews. Marxist sociologists today remain focused on the relations between these things, with a keen int erest in how advanced global capitalism (and the mass consumerism that comes with it) influences our values, expectations, identities, relationships with others, and our everyday lives.The connections between critical consciousness and progressive social change:  Much of Marxs theoretical work and activism was focused on understanding how to liberate the consciousness of the masses from domination by the capitalist system, and following that, to foster egalitarian social change. Marxist sociologists often focus on how the economy and our social norms and values shape how we understand our relationship to the economy and our place within the social structure relative to others. There is a general consensus among Marxist sociologists that the development of a critical consciousness of these things is a necessary first step to the overthrow of unjust systems of power and oppression. Though Marxist sociology is rooted in a focus on class, today the approach is also used by sociologists to study issues of gender, race, sexuality, ability, and nationality, among other things. Offshoots and Related Fields Marxist theory is not just popular and fundamental within sociology but more broadly within the social sciences, humanities, and where the two meet. Areas of study connected to Marxist sociology include Black Marxism, Marxist Feminism, Chicano Studies, and Queer Marxism. Updated by Nicki Lisa Cole, Ph.D.

Summer Camp Descriptive Essay - 1100 Words

â€Å"Summer Camp† The bus decelerated to a stop and we were there, Crystal Lake. I wasn’t there willingly, but my parents made me go with my cousin, Sandra. They said that this would help bring me closer to God, but I think they just needed a break from me. I’ve always detested summer camp, especially the ones from church. The kids from there are always so annoying, and I’m forced to put up with them for a whole week. When we got to the camp, it was about 5:30. The group leaders assigned our cabins, which consisted of four bunk beds, two dressers, and a small couch. After that, we all went on a hike and came back for dinner. I was exhausted, and honestly, I was already over it. After, everyone showered and got settled into their cabins. All†¦show more content†¦The sun was setting, and the lake sparkled under the remaining sunlight, reflecting the sky’s pink and orange hues. It was beautiful here but i still longed to be home. My thoughts were almost interrupted when i saw it. There, on the other side of the lake stood the strange woman, staring directly at me. â€Å"Are you alright?† inquired Sandra. I froze. I didn’t know what to tell her. I debated whether or not I should say something. I stayed quiet for a moment, then, I finally answered her. â€Å"Yeah, I’m fine why?† I replied. Sandra tilted her head and looked at me for a moment. â€Å"You seem a little...off. Are you sure you’re alright?† she asked, once again. â€Å"Mhm, I’m fine,† I told her. She looked at me for a moment then just nodded. I wasn’t fine though, I felt uneasy. When it got later, we went to our cabin, and once again, the girls stayed up talking while I listened to my music. I turned up the volume all the way and tried, unsuccessfully to get the thought out of my mind. I wasn’t sure why she was there, or if she was even a threat, but the way she just stood there staring at me creeped me out. 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